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hca_521_unit_2_read.pdf

healthcare_information_technology_discuss_two.docx

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Health Information
Professionals
LEARNING OUTCOMES
H
I should be able to:
After completing this chapter, you

Describe the history of health
G information management and organizations

Differentiate the roles of health information professionals
G

Describe the organizational hierarchy of HIM and IT departments
S allied healthcare occupations

Compare various nonclinical
, manager

Explain the role of a project

Understand how skill sets from multiple disciplines can help you in your career
S
H
A
Acronyms are used extensively in both medicine and computers. The following
N
acronyms are used in this chapter.
AAPC
American Academy of I
CTR
Certified Tumor Registrar
Professional Coders
DISA
Data Interchange Standards
C
ACMPE
American College of Medical
Association (within ANSI)
Q
Practice Executives
DRG
Diagnosis-Related Group
ACS
American College of Surgeons
U
EDI
Electronic Data Interchange
AHDI
Association for Healthcare
EHR
Electronic Health Record
A
Documentation Integrity
ACRONYMS USED IN CHAPTER 2
EMR
Electronic Medical Record
HCPCS
Healthcare Common Procedure
Coding System
HIM
Health Information Management
HIMSS
Healthcare Information and
Management Systems Society
HIPAA
Health Insurance Portability and
Accountability Act
HIS
Health Information System
of North America
HIT
CCOW
Clinical Context Object
Workgroup
Health Information Technology;
Health Information Technician
HL7
Health Level 7 (within ANSI)
CEO
Chief Executive Officer
CIO
Chief Information Officer
CIS
Clinical Information System
CMT
Certified Medical Transcriptionist
COO
Chief Operating Officer
AHIMA
American Health Information
Management Association
AMIA
American Medical Informatics
1
Association
ANSI
American National Standards
0
Institute
APC
Ambulatory Payment
Classification
ARLNA
1
5
T
Association of Record Librarians
S
ICD-9-CM International Classification of
Diseases, Ninth Revision, Clinical
Modification
IOM
Institute of Medicine
IT
Information Technology
22
Health Information Technology and Management, First Edition, by Richard Gartee. Published by Prentice Hall. Copyright © 2011 by Pearson Education, Inc.
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HEALTH INFORMATION PROFESSIONALS
JCAHO
Joint Commission on
Accreditation of Healthcare
Organizations (now referred to
simply as the Joint Commission)
MGMA
Medical Group Management
Association
NAHQ
National Association for
Healthcare Quality
NCRA
National Cancer Registrars
Association
RHIT
OR
Operating Room
SDO
PDF
Portable Document Format
PHI
PRO
QIO
RFID
RHIA
23
Protected Health Information
Peer Review Organization (now
Quality Improvement Organization)
Quality Improvement Organization
(Formerly Peer Review Organization)
Radio-Frequency Identification
Registered Health Information
Administrator
Registered Health Information
Technician
Standards Developing
Organization (within ANSI)
H
I
G
History of Health Information Management
G
and Organizations
S
,
Thus far we have discussed facilities and locations where healthcare
is delivered and the roles of
the doctors and clinical allied healthcare workers who provide direct care to the patient. These
direct care professionals create and use the health information record. In this chapter we explore
S
some of the nonclinical healthcare professions involved in managing
health information once it
is recorded. We will also discuss a few of the professionalHassociations and standards setting
organizations that have been created to improve healthcare information systems and support
A
those who work in the field of health information.
The concept of creating and maintaining complete and accurate
medical records as a necesN
sity of healthcare is less than a century old. When the American College of Surgeons (ACS)
I
sought to improve the results of surgery by establishing minimum standards for hospitals, they
included requirements that hospitals keep records of the care C
and treatment of their patients. Prior
to the ACS initiative in 1918, records of hospitalized patients were the responsibility of the
Q
attending physician and were filed “as is” upon the patient’s discharge. These early records genU
erally consisted of nurses’ notes and often did not include admitting
or discharge diagnoses.
The ACS addressed this issue by including record-keeping
requirements
in its Hospital
A
Standardization Program:
“Accurate and complete medical records [must] be written for all patients and filed in
1
an accessible manner in the hospital, a complete medical record being one which
includes identification data; complaint; personal and family
1 history; history of the present illness; physical examination; special examinations such as consultations, clinical
0
laboratory, x-ray and other examinations; provisional or working diagnosis; medical or
surgical treatment; gross or microscopical pathological5findings; progress notes; final
1
diagnosis; condition on discharge; follow-up; and, in case
T of death, autopsy findings.”
In complying with the program, hospitals soon created S
positions for medical records clerks
to examine the medical records for missing reports, ensure their completion, and store them by
some logical filing method.
A decade after the ACS initiated its program, an organization was formed by records clerks
and named the Association of Record Librarians of North America. This was the precursor of the
health information profession. The organization changed its name to the American Association of
Record Librarians in 1941 and to the American Medical Record Association in 1970. In 1991 the
name was updated to reflect an evolution from record keeping to managing health information.
1
Bulletin of the American Association of Medical Record Librarians (March 1941): 101.
Health Information Technology and Management, First Edition, by Richard Gartee. Published by Prentice Hall. Copyright © 2011 by Pearson Education, Inc.
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CHAPTER 2
Today the organization is the American Health Information Management Association (AHIMA).
AHIMA will be discussed further later in this chapter.
From its inception, the early organization sought to improve the profession by formulating a
curriculum of study and accrediting schools to provide training for medical record librarians.
AHIMA continues that process today by sponsoring the Commission on Accreditation for Health
Informatics and Information Management Education.
From Record Systems to Information Systems
During its first 60 years, members of the medical records profession improved the processing and
handling of patient records. Charts were analyzed for deficiencies and missing items were
obtained. Charts were tracked, stored, retrieved, and indexed in various ways.
Chart contents were standardized somewhat through the creation of specific forms for specific purposes. For example, admission, discharge, physical exams, doctor’s orders, and nurses’
H by a forms committee and maintained by the medical
notes were recorded on forms designed
records department. This process is called
forms control and is still used today.
I
However, there was little standardization of medical information in the reports, except that it
G form. In other words medical records did not use a stanappeared in the appropriate box on the
dard data set or clinical vocabulary.
G(Data sets and clinical vocabulary will be explained in
Chapters 4 through 7.)
S
Medical records departments were focused and organized around the chart as a physical
, with the patient, then moved to the abstracting and billing
object to be moved around the hospital
departments, and finally stored for the long term. Medical records departments became better at
chart handling, but at a cost estimated to be from 25 to 40 percent of a hospital’s operating budget.2
2
1
6
5
FIGURE 2-1
S
H
A
N
I
C
Q
U
A
1
1
0
5
T
S
3
4
Flow of inpatient information using a paper chart.
2
B. I. Blum, Clinical Information Systems (New York: Springer-Verlag, 1986).
Health Information Technology and Management, First Edition, by Richard Gartee. Published by Prentice Hall. Copyright © 2011 by Pearson Education, Inc.
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HEALTH INFORMATION PROFESSIONALS
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Figure 2-1 shows the workflow of traditional charts:
1. Forms control is the first step. Committees meet to design and approve forms to be used
in the facility. Forms are then distributed to various departments.
2. Caregivers record nurses’ notes, doctor’s orders, and other documents during the
patient’s stay.
3. Upon discharge, the patient’s chart is collected, assembled, and analyzed by the health
information management (HIM) department.
4. The chart is then abstracted and assigned codes for billing.
5. The chart is examined for completeness. If documents or signatures are missing, HIM
personnel contact doctors or other departments to correct the chart deficiencies.
6. When the chart is complete, it is filed.
H
Regulatory reporting, billing, and accreditation requirements made it increasingly necesI
sary to be able to abstract, aggregate, and report information collected from the charts of all
patients treated by the facility. It became obvious that theGtask had evolved from managing
health records to managing health information (which included managing the charts). Thus,
G
in 1991 the American Medical Record Association became the American Health Information
Management Association and the name for this profession S
was changed to health information
management.
,
HIM, HIT, and HIS
S
The renamed health information management (HIM) departments continued to compile, provide,
H
and control access to patient records, as well as ensure the completeness
and accuracy of those
records. Other HIM functions include coding, abstracting, and
aggregating
health information for
A
billing, reporting, and research purposes. However, two other changes significantly affected the
field of health information management, as discussed next. N
First, beginning in about 1970, hospitals began to install
I computer systems. At first these
were large central computers called mainframes, which required special technicians to operate.
C information, the department
Although mainframes did not contain much actual patient medical
was called the health information system (HIS) department.QBy 1990, computer terminals and
networked computers were prevalent in every department. By 1996 the majority of ambulatory
U
facilities had computerized as well; 85 percent of physicians in private practices were using
3
computers to run their offices.
A
Facilities were becoming computerized but the HIS or information technology (IT)
department was not usually a part of HIM. Furthermore, IT employees were not health infor1
mation technicians (HITs), who report to the health information
management administrator.
This was a problem. If health information was going to be
stored
on and managed by com1
puters, there needed to be coordination in defining content and maintaining security. One
0
solution common at many facilities is to place both departments
under the chief information
officer (CIO).
5
The second major change for HIM occurred in 1996 when Congress passed the Health
T will be covered extensively in
Insurance Portability and Accountability Act (HIPAA). HIPAA
Chapter 3, but briefly its effect on HIM and HIS was threefold:
S
1. It mandated protection for the privacy of patient records.
2. It established specific standards for data codes and data sets.
3. It required security policies for patient information stored electronically.
3
Medical Manager Research and Development, Alachua, FL.
Health Information Technology and Management, First Edition, by Richard Gartee. Published by Prentice Hall. Copyright © 2011 by Pearson Education, Inc.
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CHAPTER 2
Chief Information
Officer
Director of Information
Technology
Director of Health
Information Management
Data Resource
Administrator
Database
Administrator
Information
Security Manager
Network Engineer
Hardware Engineer
Integration Architect
Enterprise
Application Specialist
IT Project Manager
System Analyst
Health System
Specialist
HIS Department
Technician
Clerical Supervisor
H
I
G
G
S
,
S
H
A
N
I
C
Q
U
A
1
1
0
5
T
S
File Clerks
Document
Imaging
Release of
Information
Birth/Death
Certificates
Transcription Supervisor
Transcriptonists
Coding Supervisor
Clinical Coding
Specialist
Inpatient Coding
Associate
Outpatient Coding
Associate
FIGURE 2-2 Abridged organizational chart for IT and HIM departments
under the CIO.
Health Information Technology and Management, First Edition, by Richard Gartee. Published by Prentice Hall. Copyright © 2011 by Pearson Education, Inc.
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HEALTH INFORMATION PROFESSIONALS
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Increased Computerization
Hospitals and some ambulatory facilities are accredited by the Joint Commission (JCAHO) discussed in Chapter 3. The Joint Commission views health information as an important resource to
be managed and states that “managing health information is an active, planned activity.”4
However, the increasing number of documents being produced per patient and the fact that information stored in thousands of paper charts is not easy to use to improve health brought about an
interest in computerizing the records.
In the past century, medical records were primarily paper and, unfortunately, in most facilities they still are. In 1991 the Institute of Medicine (IOM) called for the creation of “an electronic
patient record that resides in a system specifically designed to support users by providing accessibility to complete and accurate data, alerts, reminders, clinical decision support systems, links
to medical knowledge, and other aids.”5
Almost two decades later, ambulatory as well as acute care facilities are moving from paper
H
to electronic medical record systems. As a result, health information
managers must become well
acquainted with information technology. Today, even paper forms
are
often designed to facilitate
I
scanning into electronic health records.
G
As facilities have moved away from paper toward electronic
records, the IT and HIM
departments have become more intertwined. For that reason
G many healthcare facilities put
both departments under the authority of the CIO as shown in the organizational chart in
S
Figure 2-2.
Before proceeding to the next section, let us review some
, of the acronyms used for these
departments and positions because they are so similar. Detailed job descriptions are provided
later in the chapter.



S
The chief information officer (CIO) is responsible for all of the hospital information
H
systems, both HIM and IT departments.
A the security, accuracy and
Health information management (HIM) is concerned with
completeness of the health records and the information that can be reported from them.
N
• A health information technician (HIT) is an HIM employee usually focused on a
I
specific aspect of the HIM department.
Chealth information system (HIS)
The information technology (IT) department operates the
computers. The IT department may also be responsible Q
for the phone systems and other
computers as well.
U
• IT technicians (also called network technicians, system analysts, database administrators,
A need to access patient informaetc.) keep the computers operating. Although they may
tion to do their job, they do not enter or use health information.
1
Health Information Professionals 1
0 in the health information field.
There are many nonclinical allied health professions available
Some of these jobs are more prevalent in inpatient acute care5facilities than outpatient settings. A
large hospital may have a number of people who perform the same job, for example, coding specialists in the billing department. In smaller clinics, a singleTperson may perform multiple jobs.
For example, a small single-doctor practice may have only two
S office staff and they might each
perform several HIM tasks.
Also some jobs are outsourced to a company that specializes in a particular HIM service. A
typical example of this is medical transcription, which is often done by transcriptionists who work
for a transcription service company, not the doctor. Another example might be computer security
consultants or system trainers who may work for the HIS vendor, not the hospital or doctor.
4
Comprehensive Accreditation Manual for Hospitals (Chicago: Joint Commission, 2005), IM-1.
R. S. Dick and E. B. Steen, The Computer-based Patient Record: An Essential Technology for Health Care (Washington,
DC: National Academy Press, 1991, revised 1997, 2000).
5
Health Information Technology and Management, First Edition, by Richard Gartee. Published by Prentice Hall. Copyright © 2011 by Pearson Education, Inc.
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CHAPTER 2
A REAL-LIFE STORY
Building an All-Digital Hospital
By Tanya Townsend
Tanya Townsend is the director of information technology at Saint Clare’s Hospital
in Schofield, Wisconsin. Tanya has a master’s degree in medical informatics.
W
hen Ministry Health Care decided to construct Saint Clare’s
Hospital, one of the objectives was to try to use only digital
records. Potentially, what was accomplished at our hospital could
then be rolled out to the other 14 Ministry hospitals. I was fortunate to be involved in the development of this wonderful new
facility.
I originally started out in health information management, but
even as I was finishing school it was apparent that everything was
going to change to electronic patient records. I wanted to get
involved in the IT portion of making that happen, so I went on to
get my master’s in medical informatics.
Initially I worked as an analyst on a health information management system, which was perfect because of my HIM background. From there I continued to evolve in healthcare IT. I worked
on starting a new hospital in Green Bay, Wisconsin. I was responsible for all of the application installation and coordination there.
Saint Clare is actually the third new construction hospital I’ve had
the opportunity to be a part of.
Our core objective at Saint Clare’s was to come up with the
highest level of operational efficiency that could be achieved using
technology as well as patient safety, clinical excellence, and great
customer service—all of that can be facilitated through technology.
Saint Clare’s Hospital is partnered with an ambulatory setting,
the Marshfield Clinic. We needed the hospital systems to integrate
data with the ambulatory setting and any departmental applications that we had. Based on a detailed system selection process,
we went with a best-of-breed approach and interfaced the systems by using HL7 and CCOW. [Author’s note: HL7 stands for
Health Level Seven and CCOW stands for Clinical Context Object
Workgroup.]
We wanted to make sure we were supporting and optimizing
the flow of information across the continuum of healthcare. So
whether you are in the ambulatory clinic, in the hospital, in the
emergency department, even in the OR [operating room], we have
all of those systems tied together. Eliminating duplication and
providing information anytime, anyplace is a win for the patient as
well as the provider.
One of the key things that made us very successful was that
[the process] was very collaborative. For this campus we used a
project management office extensively on both IT as well as nonIT projects to pull everything together.
As we started developing and designing, we realized there
were no maps to follow as we were pioneers in building this alldigital hospital. It was suggested we document each process.
What steps were invo …
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